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ruled out and treated before considering permanent geneities in atrial and ventricular repolarization, the
pacemaker insertion. The most certain indications extend of myocardial damage, scar formation, auto-
for permanent pacing include the following: Symp- nomic system distortion, glucose fluctuations as well
tomatic bradycardia due to sinus node dysfunction as structural and electrical alterations have been well
(sick sinus syndrome), Symptomatic chronotropic identified. The causal pathophysiological and elec-
incompetence, Second- or third-degree AV block in trophysiological mechanisms and effect of specific
asymptomatic awake patients in sinus rhythm result- therapies however are warranted in further studies.
ing in periods of asystole longer than 3.0 seconds
or ventricular rates less than 40 beats per minute, References:
Second -or third-degree AV block in asymptomatic 1. Garcia MJ, McNamara PM, Gordon T, Kannel WB. Morbidity and
awake patients in atrial fibrillation resulting in pauses mortality in diabetics in the Framingham population. Sixteen year
of at least 5 seconds, Neurocardiogenic syncope, in follow-up study. Diabetes 1974; 23: 105-111
the setting of chronic bifascicular block for advanced 2. Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA.
second-degree AV block or intermittent third-degree Independent risk factors for atrial fibrillation in a population-based cohort.
AV block or Type II second-degree AV block or alter- The Framingham Heart Study. JAMA 1994; 271: 840-844
nating bundle branch block . 3. Huxley RR, Filion KB, Konety S, Alonso A. Meta-analysis of cohort and
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case-control studies of type 2 diabetes mellitus and risk of atrial brillation.
The implant of defibrillators and cardiac resynchro- Am J Cardiol 2011; 108: 56-
nization devices should also follow the same indica- 4. Stahn A, Pistrosch F, Ganz X, Teige M, Koehler C, Bornstein S, Hanefeld
tions as for the normal population. Indications for im- M. Relationship between hypoglycemic episodes and ventricular arrhyth-
plantable cardioverter-defibrillator (ICD) implant can mias in patients with type 2 diabetes and cardiovascular diseases: silent
be divided into 2 broad categories: secondary pro- hypoglycemias and silent arrhythmias. Diabetes Care 2014; 37: 516-520
phylaxis against sudden cardiac death and primary 5. Pistrosch F, Ganz X, Bornstein SR, Birkenfeld AL, Henkel E, Hanefeld M.
prophylaxis. An ICD is recommended as therapy in Risk of and risk factors for hypoglycemia and associated arrhythmias in
survivors of cardiac arrest due to VF or hemodynam- patients with type 2 diabetes and cardiovascular disease: a cohort study
under real-world conditions. Acta Diabetol 2015; 52: 889-895
ically unstable VT. ICD implantation is appropriate for
primary prophylaxis for LVEF <35% and NYHA class I 6. Ball J, Carrington MJ, McMurray JJ, Stewart S. Atrial brillation: pro le and
26
to III symptoms . The SCD Heft trial (23) showed that burden of an evolving epidemic in the 21st century. Int J Cardiol 2013;
167: 1807-1824
in patients with NYHA class II or III CHF and LVEF of
≤35 % amiodarone has no favorable effect on survival, 7. Movahed MR, Hashemzadeh M, Jamal MM. Diabetes mellitus is a
strong, independent risk for atrial fibrillation and flutter in addition
whereas single-lead, shock-only ICD therapy reduc- to other cardiovascular disease. Int J Cardiol 2005; 105: 315-318
es overall mortality by 23 percent. As compared with 8. Kato T, Yamashita T, Sekiguchi A, Sagara K, Takamura M, Takata S,
placebo, amiodarone therapy was associated with a Kaneko S, Aizawa T, Fu LT. What are arrhythmogenic substrates in
similar risk of death and ICD therapy was associated diabetic rat atria? J Cardiovasc Electrophysiol 2006; 17: 890-894
with a decreased risk of death (hazard ratio, 0.77; 97.5 9. Kato T, Yamashita T, Sekiguchi A, Tsuneda T, Sagara K, Takamura
percent confidence interval, 0.62 to 0.96; P=0.007). M, Kaneko S, Aizawa T, Fu LT. AGEs-RAGE system mediates atrial
DM was seen in 32% of the placebo and 31% of the structural remodeling in the diabetic rat. J Cardiovasc Electrophysiol
ICD group. The observed benefit of ICD therapy was 2008; 19: 415-420
similar in both DM and non-DM patients . Recent 10. Tesfaye S, Boulton AJM, Dyck PJ. Diabetic neuropathies: update on
27
meta-analyses of CRT trials have suggested that the definitions, diagnostic criteria, estimation of severity, and treatments.
benefit of CRT is dependent on QRS duration, with Diabetes Care 2010;33(10):2285–93.
a significant benefit associated with CRT in patients 11. Chao TF, Suenari K, Chang SL, Lin YJ, Lo LW, Hu YF, Tuan TC, Tai CT, Tsao
with QRS ≥150 ms, but not in patients with QRS <150 HM, Li CH, Ueng KC, Wu TJ, Chen SA. Atrial substrate properties and
25
ms . Clinical response to CRT is also dependent on outcome of catheter ablation in patients with paroxysmal atrial brillation
associated with diabetes mellitus or impaired fasting glucose. Am J Cardiol
QRS morphology, with the greatest response for pa- 2010; 106: 1615-1620
tients with LBBB and QRS ≥150 ms. 12. Lip GY, Varughese GI. Diabetes mellitus and atrial fibrillation: perspectives
on epidemiological and pathophysiological links. Int J Cardiol 2005; 105:
CONCLUSION 319-321
AF and VA are most common form of arrhythmias, 13. Huxley RR, Alonso A, Lopez FL, Filion KB, Agarwal SK, Loehr LR, So-
which lead to cardiovascular complications and mor- liman EZ, Pankow JS, Selvin E. Type 2 diabetes, glucose homeostasis
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tality in patients with DM. The incidence of CHB and study. Heart 2012; 98: 133-138
bifascicular blocks are higher in DM. The risk of in- 14. Fatemi O, Yuriditsky E, Tsioufis C, Tsachris D, Morgan T, Basile J,
fection of implanted devices is high. Risk factors for Bigger T, Cushman W, Goff D, Soliman EZ, Thomas A, Papademetriou
an arrhythmogenic substrate in DM, such as hetero- V. Impact of intensive glycemic control on the incidence of atrial fibril-
lation and associated cardiovascular outcomes in patients with type 2

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